Failure to Review and Discontinue PRN Psychotropic Medication per Policy
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-anxiety medication, lorazepam, had a stop date and was reevaluated by a physician after 14 days as required by facility policy. The physician's order for lorazepam, initiated for anxiety, irritability, and restlessness, did not specify a stop date, and there was no documented evidence of a physician reevaluation for continued use after the initial 14-day period. Both the LVN and the DON confirmed that the medication order should have been reviewed and either renewed or discontinued within 14 days, in accordance with facility policy and procedure. The resident involved had a history of encephalopathy, type 2 diabetes mellitus without complications, and anxiety disorder. Assessment records indicated moderate cognitive impairment and significant dependence on staff for daily activities, including eating, hygiene, and dressing. Despite these needs and the facility's policy requiring timely review of PRN psychotropic medications, the required physician evaluation and documentation for continued use of lorazepam were not completed.